SOUTH CAROLINA VOTER REGISTRATION
Registration Number
MAIL APPLICATION
Check One:
Are you a citizen of the United States of America?
Yes  No 
Will you be 18 years of age on or before election day? Yes  No 
If you checked ‘NO’ in response to either of these questions,
DO NOT complete this form.
NAME
New Registration
(Check above if moving from one county to another)
Address or name change within the same county
Last
First
Male
SEX
RACE
White
Black/African
American Asian
MI
Native
Hispanic American
SOCIAL SECURITY NUMBER **
Other
Specify
_
Female
Street
ADDRESS
WHERE YOU
LIVE
Suffix
Apt Number
City
State
_
Inside City Limits
Yes
No
Zip Code
Would you like to be a poll worker?
Yes
(Physical Address)
No
Street or Post Office Box
MAILING
ADDRESS
City
(if different
from above)
Month
BIRTHDATE
Precinct
PREVIOUS
State
Day
Year
County
Zip Code
Home
PHONE #
(
State
Work
)
(
)
Previous Name
REGISTRATION/NAME
Voter Declaration – (read and sign below)
I swear or affirm that:
-I am a citizen of the United States of America
-I will be 18 years of age on or before Election Day
-I am a resident of South Carolina, this county and precinct
-I am not under a court order declaring me mentally incompetent
-I am not confined in any public prison resulting from a conviction of a crime
-I have never been convicted of a felony or offense against the election laws OR
if previously convicted, I have served my entire sentence, including probation
or parole, or I have received a pardon for the conviction
-the address listed above is my only legal place of residence,
and I claim no other place as my legal residence
Signature
If you do not have a street name or number, draw a diagram of the
area in which you live. Show your house in relation to local
landmarks such as schools, churches, stores, etc. Be sure to label the
streets or roads.
Date of Application
Whoever shall, willfully and knowingly, swear (or affirm) falsely in taking any oath required
by law shall be guilty of perjury and, on conviction, incur the pains and penalties of the offense.
ID Required: If you are registering for the first time in this county, you must attach a copy of a current valid photo ID or a copy of a current utility bill, bank
statement, paycheck or other government document that shows your name and address in this county. If you do not provide this identification now, you will
be required to provide this information when you vote. Voters who are age 65 and over, voters with disabilities, members of the U.S. Uniformed Services or
Merchant Marines and their families, and U.S. Citizens residing outside the U.S. are exempt from this requirement.
Check here if you are exempt.
** Social Security Number is required by the S.C. Code of Laws 7-5-170. This number is used for internal purposes only and eliminates multiple
registrations by a single individual. Your Social Security Number is not released to any unauthorized individual.
For Voter Registration Board Use Only
Approved
Disapproved by __________________________________ (Member, Voter Registration Board) Date ______________